Preparing for HIEs and Integrated Health Informatics: Ways that Laboratories Can Add Major Value. Telepathology. Synoptic Reporting.

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1 Preparing for HIEs and Integrated Health Informatics: Ways that Laboratories Can Add Major Value Philip Chen, MD, PhD 2011 Executive War College January 30, 2011 Things we will not discuss today Networks LIS Hardware Security/ HIPAA Web Portal Middle Wares Software Digital Imaging Interface Engine Gene Arrays Telepathology Proteomics Pharmacogenomics Synoptic Reporting Cancer Registry Infection Control EMR PHR LOINC/HL7/ SNOWMED Epidemiology Clinical Outcome PMS RHIO/HIE Specimen Repository

2 What we will discuss: Market force What are the emerging demands in our market place? What can we do to align our services (supplies) to meet those demands? How do we do it and can we steer the demands? What are the values of what we do? Market Demands: Emerging Healthcare Delivery Models Fee-for-service, CPT-based reimbursement is leaving and will be replaced by: Performance/outcome-based reimbursement and incentives/penalties Pay-for-Performance (P4P)* e.g., Diabetes Recognition Program (NCQA) Physician Quality Reporting Initiatives (PQRI s)* Breast and colorectal cancer pt, pn categories and histologic grades; CLL baseline flow cytometry; 6 more to come in 2011 HIT Meaningful Use (HITECH Act)* Clinical Quality Measures (CQM s)* * Already deployed or likely to stay

3 Emerging Healthcare Delivery Models Coordinated/integrated care models Patient-centered Medical Homes (PCMH) Accountable Care Organizations (ACO s)* Value-based Insurance Design (VBID)* Institution and Provider tiering (Private payers) Bundled Payment* (by Acute Care Episodes inclusive of hospital, professional, lab, imaging, pharmacy and ambulatory care) *Already deployed and likely to stay ACO Requirements 1) Have a formal legal structure to receive and distribute shared savings 2) Have a sufficient number of primary care professionals for the number of assigned beneficiaries (to be 5,000 at a minimum) 3) Agree to participate in the program for not less than a 3-year period 4) Have sufficient information regarding participating ACO health care professionals to support beneficiary assignment and for the determination of payments for shared savings. 5) Have a leadership and management structure that includes clinical and administrative 6) Have defined processes to (a) promote evidenced-based medicine, (b) report the necessary data to evaluate quality and cost measures (this could incorporate requirements of other programs, such as the Physician Quality Reporting Initiative (PQRI), Electronic Prescribing (erx), and Electronic Health Records (EHR), and (c) coordinate care 7) Demonstrate it meets patient-centeredness criteria, as determined by the Secretary.

4 Where is the beef - ACO Shared Savings ACO Launched Projected Target Actual Shared Savings Shared Savings must come from new services and operations. VBID Private sector s response to ACO s? Providing financial incentives to both providers and patients to achieve better outcome Allow self-insured plans to change third party administrator Similar to ACO s, with plans to shift $$ s away from fee-forservice

5 Market Demands HIT Meaningful Use: Two questions may share the same answer What do we do to meet the meaningful use requirements? What do we do to help our clients to meet the requirements? MU requirements related to Pathology EPs 15 Core Objectives (8/15) 1. Computerized physician order entry (CPOE) 2. E-Prescribing (erx) 3. Report ambulatory clinical quality measures to CMS/States 4. Implement one clinical decision support rule 5. Provide Patients with an electronic copy of their health information, upon request 6. Provide clinical summaries for patients for each office visit 7. Drug-drug and drug-allergy interaction checks 8. Record demographics 9. Maintain an up-to-date problem list of current and active diagnoses 10. Maintain active medication list 11. Maintain active medication allergy list 12. Record and chart changes in vital signs 13. Record smoking status for patients 13 years or older 14. Capability to exchange key clinical information among providers of care and patient-authorized entities electronically 15. Protect electronic health information

6 MU requirements related to Pathology EPs Choose 5 Menu Objectives* (5/10) Drug-formulary checks Incorporate clinical lab test results as structured data Generate lists of patients by specific conditions Send reminders to patients per patient preference for preventive/follow up care Provide patients with timely electronic access to their health information Use certified EHR technology to identify patient-specific education resources and provide to patient, if appropriate Medication reconciliation Summary of care record for each transition of care/referrals Capability to submit electronic data to immunization registries/systems Capability to provide electronic syndromic surveillance data to public health agencies CQM: Additional Set for EPs (16/38) 1. Diabetes: Hemoglobin A1c Poor Control 2. Diabetes: Low Density Lipoprotein (LDL) Management and Control 3. Diabetes: Blood Pressure Management 4. Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) 5. Coronary Artery Disease (CAD): Beta-Blocker Therapy for CAD Patients with Prior Myocardial Infarction (MI) 6. Pneumonia Vaccination Status for Older Adults 7. Breast Cancer Screening 8. Colorectal Cancer Screening 9. Coronary Artery Disease (CAD): Oral Antiplatelet Therapy Prescribed for Patients with CAD 10. Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 11. Anti-depressant medication management: (a) Effective Acute Phase Treatment,(b)Effective Continuation Phase Treatment 12. Primary Open Angle Glaucoma (POAG): Optic Nerve Evaluation 13. Diabetic Retinopathy: Documentation of Presence or Absence of Macular Edema and Level of Severity of Retinopathy 14. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care 15. Asthma Pharmacologic Therapy 16. Asthma Assessment 17. Appropriate Testing for Children with Pharyngitis 18. Oncology Breast Cancer: Hormonal Therapy for Stage IC-IIIC Estrogen Receptor/Progesterone Receptor (ER/PR) Positive Breast Cancer 19. Oncology Colon Cancer: Chemotherapy for Stage III Colon Cancer Patients

7 CQM continued (16/38) 20.Prostate Cancer: Avoidance of Overuse of Bone Scan for Staging Low Risk Prostate Cancer Patients 21.Smoking and Tobacco Use Cessation, Medical assistance: a) Advising Smokers and Tobacco Users to Quit, b) Discussing Smoking and Tobacco Use Cessation Medications, c) Discussing Smoking and Tobacco Use Cessation Strategies 22.Diabetes: Eye Exam 23.Diabetes: Urine Screening 24.Diabetes: Foot Exam 25.Coronary Artery Disease (CAD): Drug Therapy for Lowering LDL-Cholesterol 26.Heart Failure (HF): Warfarin Therapy Patients with Atrial Fibrillation 27.Ischemic Vascular Disease (IVD): Blood Pressure Management 28.Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 29.Initiation and Engagement of Alcohol and Other Drug Dependence Treatment: a) Initiation, b) Engagement 30.Prenatal Care: Screening for Human Immunodeficiency Virus (HIV) 31.Prenatal Care: Anti-D Immune Globulin 32.Controlling High Blood Pressure 33.Cervical Cancer Screening 34.Chlamydia Screening for Women 35.Use of Appropriate Medications for Asthma 36.Low Back Pain: Use of Imaging Studies 37.Ischemic Vascular Disease (IVD): Complete Lipid Panel and LDL Control 38.Diabetes: Hemoglobin A1c Control (<8.0%) What do these models have in common? Focus on population management Coordinated care delivered by integrated primary and specialty network Focus on patient outcome Require evidence-based practice Health IT implementation for quality measure reporting Focus on overall healthcare cost, rather than itemized fee reduction

8 What we will discuss: Market force What are the emerging demands in our market place? What can we do to align our services (supplies) to meet those demands? How do we do it and can we steer the demands? What are the values of what we do? Delivering values of pathology information begins with understanding our customers *Order Diagnostic Tests/Procedures *Population health management *Chronic disease management *Follow up to evaluate tx efficacy, safety, toxicity *Review Results

9 What constitute Values? Practicing evidence-based medicine Better Clinical Outcome More efficient use of healthcare resources The ultimate goal is a healthier population There is only one best way. Delivering values of pathology information begins with understanding our customers *Order Diagnostic Tests/Procedures *Population health management *Chronic disease management *Follow up to evaluate for tx efficacy, safety, toxicity *Review Results

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11 Use Cases to drive Information System Development Case 1: Client submits sample for RPR screen with reflex to Titer, if reactive. Test result is Reactive and titer is performed. Subsequent patient samples are submitted to follow course of disease treatment over time. Only the Quantitative (titer) RPR should be ordered but sometimes the RPR screen is ordered and when test comes up Reactive, the titer is performed. RPR test set: F200 RPR Quant (Titer): F201 Need EES rule to ensure that follow-up RPRs on previously screened Reactive patients are only ordered as RPR Quant (Titer) Test Sets. Case 2: Client X always wants Prothrombin Time (Test Set I200) results copied to Client W and Z. Case 3: HIV geno/phenotyping test set has been replaced with a new test set. Clients still occasionally order the old test set. Old test set: E362 New test set: F235 Need EES rule to substitute F235 for E362 when E362 is ordered. Case 4: If Sendaway test set X is ordered and it has been determined that Reference Lab utilized will third party bill and the ordering client is not a Client Bill type, the Sendaway supervisor is alerted to follow-up. This scenario needs Murray s input for further definition. Case 5: If Client Z orders any tests Sendaway Supervisor alerted to review for potential order entry errors. Case 6: Individuals only need to be tested for Cystic Fibrosis Carrier status once. Need EES rule to check to see if Test Set W100 (CF Carrier Screen) has been previously ordered on this patient. If patient has already been tested for CF Carrier Status, alert Customer Service to follow up with client. HIV-1/2 Antibody Test** Repeatedly Reactive (Or Single Reactive OraQuick) Negative No follow-up needed Positive Confirmed positive, refer For medical management Significant viral load (> 10,000 copies/for typical primary infection) Western Blot (WB) Intermediate Repeat WB in one month or HIV PCR, Quantitative*, ** (For patients with no history of HIV treatment) Turn Round Time = 3 days Low viral load (<2,000 copies/ml) consider false positive result and repeat testing Negative If recent exposure (< 3 mo.) or high risk suspected No recent exposure and low Risk * Quantitative HIV PCR can also be used as baseline for treatment considerations and follow up in confirmed cases ** Please see Special Considerations section for pregnant women close to delivery

12 Delivering values of pathology information begins with understanding our customers *Order Diagnostic Tests/Procedures *Population health management *Chronic disease management *Follow up to evaluate for tx efficacy, safety, toxicity *Review Results Pattern Recognition Serum Iron Transferrin Saturation Ferritin Imp Panic Severe+Severe Mod Slight LN N HN Slight Mod SevereSevere+Severe++Panic Imp Patterns define clinical conditions. In this case, iron deficiency. Additional evidence-based patient management guidelines.

13 Clinical annotation of test results An old pathology practice revived with new technology Delivering values of pathology information begins with understanding our customers *Order Diagnostic Tests/Procedures *Population health management *Follow up to evaluate for tx efficacy, safety, toxicity *Chronic disease management *Review Results

14 Examples of LES functions: Doctor-specific actions based on results Dr. Smith would like to have reflex A1c for glucose >126 if the patient is more than 45 years old Dr. Smith (a hematologist) does not want manual differentials or pathologist review on patients who had differentials within the last 2 days (when assessing treatment for ITP or other chemo progress) Dr. Smith (a hematologist) wants all his patients to receive manual diff on a cutoff criteria that is different from the ones established for the lab. Dr. Smith wants a HCV viral load (instead of RIBA) performed if HCV Ab is positive Dr. Smith wants Hepatitis panel performed if LFT s are elevated Dr. Smith wants to cancel genotyping if the patient s viral load is less than 10,000 and a previous genotyping was performed within a year Doctor-specific critical call list

15 LIS APIS Results delivered to HIS with appropriate flags (Currently in place) At signout Is this a Significant Pathology report: YES NO Results reported to Unable to reach provider via Critical Result Reporting Complete Sign out Critical (life-threatening) LAB results are called to provider 24/7 by Lab. Provider should follow up immediately. Significant PATHOLOGY/LAB results are called to provider by Lab/Pathology. Provider should follow up ASAP. Abnormal Pathology/Lab results are flagged in patient s chart. No calls. NOTE: Currently Pathology/Lab provides outbound calls to provider as described above but does not distinguish from. Significant pathology result flag sent in HL-7 interface to HIS EPIC, Meditech, Cerner Automated Paging Service Application to deliver outbound SMS to provider pagers, cell phones, and/or s EPIC Meditech LIS flags results based on criteria approved by MEC Cerner Critical (life-threatening) LAB results are called to provider 24/7 by Lab. Provider should follow up immediately. Significant PATHOLOGY/LAB results are called to provider by Lab/Pathology. Provider should follow up ASAP. Abnormal Pathology/Lab results are flagged in patient s chart. No calls. NOTE: Currently Pathology/Lab provides outbound calls to provider as described above but does not distinguish from. 1. All open Encounters are monitored daily currently by clinical staff 2. Create an Aging Significant Encounter report for all encounters not closed after 48 hours and deliver to department chair 3. Create an Aging Significant Encounter report for all encounters not closed after 72 hours and deliver to department chair AND Risk Management Results delivered to provider inbox with a message reminding provider to communicate with patient and to close Significant Result Encounter in patient s chart A reflex Significant Result Encounter is opened in patient s chart. To close the encounter, a pop-up dialogue must be answered. Disease/Condition known to patient, No contact needed Patient/Guardian contacted on Close Encounter Results delivered EMR with a message reminding provider to close Significant Result Procedure in patient s chart A reflex Significant Result Procedure is ordered in patient s chart. To close the order, a pop-up dialogue must be answered. Disease/Condition known to patient, No contact needed Patient/Guardian contacted on Complete Procedure 1. All incomplete Procedures are monitored daily currently by clinical staff 2. Create an Aging followup report for all significant result procedures not completed after 48 hours and deliver to department chair 3. Create an Aging followup report for all significant result procedures not completed after 72 hours and deliver to department chair AND Risk Management

16 Delivering values of pathology information begins with understanding our customers *Order Diagnostic Tests/Procedures *Population health management *Follow up to evaluate for tx efficacy, safety, toxicity *Chronic disease management *Review Results PQRI/DRP The incentive payments (1.5% of Medicare eligible payments) are issued through PQRI, a Medicare Program ( PQRI currently has 100+ measures, Diabetes reporting was the first one implemented Provider can report diabetes measures through DRP, administered by National Committee for Quality Assurance (NCQA) (

17 DRP Benefits and Measures

18 Accession # Chart# Request Date Patient Name Ordering Physician Sex D.O.B Diagnosis Codes XXXXXXX XX 10/10/2005 SMITH, JOHN COOPER MD ANDERSON M 12/19/ XXXXXXX XX 10/5/2005 JONES, JANNIFER CHEN MD PHILIP M 6/19/1949 V70.0; XXXXXXX XX 10/6/2005 BUSH, GEORGE CHEN MD PHILIP F 7/27/1945 V72.31; 15.4 XXXXXXX XX 10/7/2005 DANER, JEFFREY A CHEN MD PHILIP M 9/12/1962 HA1C ;272.4; XXXXXXX XX 12/2/2005 JACKSON, YVONNE COOPER MD ANDERSON F 11/16/ XXXXXXX XX 10/14/2005 LUCAS, EMORY L COOPER MD ANDERSON M 9/2/1971 V70.0; XXXXXXX XX 11/30/2005 PHILLIPS, JENESE COOPER MD ANDERSON F 7/27/ ;V XXXXXXX XX 10/31/2005 JACKSON, CURTIS CHEN MD PHILIP M 5/12/ XXXXXXX XX 10/10/2005 RICE, CONDI CHEN MD PHILIP M 6/29/ ;V XXXXXXX XX 10/11/2005 PRESLEY, ELVIS CHEN MD PHILIP F 6/16/ ;V XXXXXXX XX 11/2/2005 TAYLOR ELIZABETH CHEN MD PHILIP F 6/11/ ; XXXXXXX XX 11/3/2005 LI, AN COOPER MD ANDERSON F 12/23/ XXXXXXX XX 11/9/2005 ARMSTRONG, LANCE COOPER MD ANDERSON F 9/14/1947 V72.31;

19 Peer comparison Clients: XXXXXXX From 10/01/ /31/2005 Clients: YYYYYYY From: 10/01/ /31/2006 Test Code Description TOTAL TEST COUNT 1000 COMPLETE BLOOD COUNT LIPID PANEL COMP METABOLIC PANEL TSH W/REFLEX TO FREE T RPR, SYPHILIS SCREEN URINALYSIS HEMOGLOBIN A1C CANCER ANTIGEN C-REACTIVE PROTEIN,HIGH CHLAMYDIA/GC DNA PROBE MAGNESIUM PSA GLUCOSE, SERUM 65 71R THIN PREP R/ HI RISK HPV THIN PREP, PAP MICROALBUMIN/CREAT RATIO HEPATIC FUNCTION PANEL PROTHROMBIN TIME 37 Test Code Description Total Test Count 10 COMP METABOLIC PANEL LIPID PANEL COMPLETE BLOOD COUNT TSH URINALYSIS HEMOGLOBIN A1C O THIN PREP, OSCEOLA PATH H PYLORI AB, IgG T-4 (THYROXINE) MICROALBUMIN, URINE THIN PREP, PAP SEDIMENTATION RATE CULTURE, URINE LDL, DIRECT PSA HEPATIC FUNCTION PANEL RHEUMATOID FACTOR PROTHROMBIN TIME 50

20 Recommendation Statement Screening for Ovarian Cancer U.S. Preventive Services Task Force (USPSTF) Ovarian Cancer (PDQ ): Screening Last Modified: 03/14/2006 Patient Version Ovarian Cancer Screening Key Points for This Section This statement summarizes the current U.S. Preventive Services Task Force (USPSTF) recommendation on screening for ovarian cancer and the supporting evidence. It updates the 1996 recommendation contained in the Guide to Clinical Preventive Services, Second Edition 1. Summary of Recommendation Tests are used to screen for different types of cancer. There is no standard or routine screening test for ovarian cancer. Tests that may detect (find) ovarian cancer are being studied: Pelvic exam Transvaginal ultrasound CA-125 assay Tests are used to screen for different types of cancer. Some screening tests are used because they have been shown to be helpful both in finding cancers early and in decreasing the chance of dying from these cancers. Other tests are used because they have been shown to find cancer in some people; however, it has not been proven in clinical trials that use of these tests will decrease the risk of dying from cancer. Scientists study screening tests to find those with the fewest risks and most benefits. Cancer screening trials also are meant to show whether early detection (finding cancer before it causes symptoms) decreases a person's chance of dying from the disease. For some types of cancer, finding and treating the disease at an early stage may result in a better chance of recovery. There is no standard or routine screening test for ovarian cancer. Screening for ovarian cancer is under study and there are screening clinical trials taking place in many parts of the country. Information about ongoing clinical trials is available from the NCI Web site 1. The U.S. Preventive Services Task Force (USPSTF) recommends against routine screening for ovarian cancer. Contents Rating: D Recommendation. Rationale: The USPSTF found fair evidence that screening with serum CA-125 level or transvaginal ultrasound can detect ovarian cancer at an earlier stage than it can be detected in the absence of screening; however, the USPSTF found fair evidence that earlier detection would likely have a small effect, at best, on mortality from ovarian cancer. Because of the low prevalence of ovarian cancer and the invasive nature of diagnostic testing after a positive screening test, there is fair evidence that screening could likely lead to important harms. The USPSTF concluded that the potential harms outweigh the potential benefits. Background Clinical Considerations Discussion Recommendations of Other Groups References Members of the Task Force Contact the Task Force Available Products Copyright and Electronic Dissemination *Exclusive contracts with favorable PMPM rate Task Force Ratings Strength of Recommendations and Quality of Evidence Delivering values of pathology information begins with understanding our customers *Order Diagnostic Tests/Procedures *Population health management *Follow up to evaluate for tx efficacy, safety, toxicity *Chronic disease management *Review Results

21 Population Health Management Integrating Clinical and Financial Outcomes # of People $$ they spend 5/50 and 20/80 Rules At OC, 5% spends 50.3% and 20% spends 83.2% of health care dollars 60% of the 5% top-spenders shifting from low spenders pool on the annual basis Identification of and designing effective intervention programs for these shifters would likely yield significant ROI. Proactive Strategies in Workplace Wellness A company that invests in its workforce... invests in its future Debbie Zimmerman, MBA Wellness Manager, Polk County School Board Philip Chen, MD, PhD Cognoscenti Health Institute

22 School Board of Polk County, Florida 37 th Largest School District in US; 8 th in FL 154 Work Locations 90,000 Students 11,000 Employees Self Funded Health Plan BCBS of FL PPO 17,000 Health Plan Participants $60,000,000 Annual Health Budget Board Funding History Per Eligible Employee per month Plan Year Funding % Inc $219 11% 2001 $244 11% 2002 $297 22% 2003 $372 25% 2004 $391 5% 2005 $415 6%

23 PCSB Diabetes Claims 11/1/02 through 10/31/03 $16,718,858 $13,794 average per diabetic 1212 diagnosed diabetics 7.5% of School Board population Screening Health Risk Appraisal (HRA) Biometrics: Lipid Panel Fasting Glucose Insulin Resistance Index Homocysteine Blood Pressure BMI (Ht/Wt) or % Body Fat Risk Factors** Obesity Smoking Hypertension Hyperlipidemia Family History of DM or CVD Sedentary Lifestyle Risk Stratification Diabetes Intervention Quarterly clinics: 2-4 HgbA1c per year Annual Microalbumin Annual Foot Exam Annual Eye Exam Two Diabetes classes Normal to Moderate Risk Pre-Diabetes* or High Risk for CVD 1 on 1 result review (10 min) 1 on 1 result review (10 min) Group Nutrition Review (30 min) Group Nutrition Review (30 min) Group Exercise Review (30 min) Group Exercise Review (30 min) 1 on 1 Nutrition/Exercise Counseling (45 min) Follow Up Alternatively, participants producing documentation for comparable PCP Semi-annual Screening management and Progress Follow Up *FG > 100 mg/dl and IRI > 3.21 (QUICKI) or > 4 Risk Factors** Annual Screening

24 Results Biometric Screening Identified Risk Factors ALL 2002 n=1777 ALL 2003 n=1777 ALL 2004 n=1654 Diabetes Cohort 2002 Diabetes Cohort 2003 n=579 Diabetes Cohort 2004 n=562 Obesity 70% 66% 59% Hypertension 23% 24% 19% Hyperlipidemia 43% 44% 29% 45% 42% 32% Diabetes Risk 50% 42% 40% 46% 42% 36% Calculating ROI All Employees Wellness Pilot Difference $2,881.83* $2,425.39* $456.44* Program Expenditures: $486,446 Program Savings: $810,637 ROI: 1:1.73 *Adjusted Per Capita

25 Focus on Diabetes

26 Participant#Sex AgeZones Health Score Medical Cost Pharmacy Cost Drugs M 46 11,11,5,11,13,13,11,11, GLUMETZA,ZYMAR M 38 11,11,5,11,13,13,9,16, OXYCODONE ACETAMINOPHE M 60 11,11,5,11,13,9,11,9, CRESTOR,VYTORIN M 60 11,11,5,11,13,9,9,16, ACIPHEX,AZITHROMYCIN,REQUIP,ROPINIROLE HCL,SIMVASTATIN,VYTORIN M 49 11,11,5,11,9,13,11,11, LOVASTATIN,LUNESTA,MOMETASONE FUROATE,NAPROXEN M 37 11,11,5,11,9,13,9,9, ZOLPIDEM TARTRATE M 52 11,11,5,11,9,9,9,9, AMOX TR POTASSIUM CLAV,AZASITE,CEFADROXIL,LEVAQUIN,LISINOPRIL HCTZ,MINOCYCLINE HCL,ZYMAR M 30 11,11,5,16,13,13,9,9, CIPROFLOXACIN HCL,FUROSEMIDE,METHYLPREDNISOLONE,OXYCODONE ACETAMINOPHE,UTIRA C M 48 11,11,5,9,13,13,9,11, AZITHROMYCIN M 63 11,11,5,9,13,9,11,16, AMLODIPINE BESYLATE BE,CARISOPRODOL,FENTANYL,GLYBURIDE,GLYBURIDE METFORMIN HC,HYDROCHLO HCL,INDOMETHACIN,JANUVIA,LIDODERM,LISINOPRIL,METHYLPREDNISOLONE,METOPROLOL SUCCINATE,NA M 61 11,11,6,11,13,13,11,11, DILT XR,LISINOPRIL HCTZ,PENICILLIN V POTASSIUM,POTASSIUM CHLORIDE,PROPOXYPHENE NAPSYLATE,ZO M 41 11,11,6,11,13,13,11,11, AZITHROMYCIN,BENZONATATE M 46 11,11,6,11,13,13,11,11, AZITHROMYCIN,BUDEPRION SR,LEVAQUIN,LEVITRA,METOPROLOL SUCCINATE,PROGRAF,SERTRALINE HCL,Z M 61 11,11,6,11,13,13,11,16, AMOX TR POTASSIUM CLAV,CHLORDIAZEPOXIDE HCL,CYMBALTA,DIOVAN HCT,MELOXICAM,NALTREXONE H F 42 11,11,6,11,13,13,11,16, ALPRAZOLAM,AZITHROMYCIN,HYDROCODONE ACETAMINOP,TRAMADOL HCL ADVAIR DISKUS,CLARITHROMYCIN ER,CYCLOBENZAPRINE HCL,IBUPROFEN,LEVAQUIN,PREDNISONE,PROAIR F 53 11,11,6,11,13,13,11,16, NAPSYLATE,XOPENEX HFA M 51 11,11,6,11,13,13,13,16, ACETAMINOPHEN CODEINE,AVELOX,BENAZEPRIL HCL,BYETTA,FUROSEMIDE,GLIPIZIDE,LEVOTHYROXINE SO SUCCINATE,METOPROLOL TARTRATE,OXYCODONE ACETAMINOPHE,PEN NEEDLE,POTASSIUM CHLORIDE,SIM F 45 11,11,6,11,13,13,13,16, ACIPHEX,EXFORGE,JANUVIA,METFORMIN HCL ER,PROMETHAZINE HCL,SIMVASTATIN F 52 11,11,6,11,13,13,13,16, ATENOLOL CHLORTHALIDON,BENICAR,LIDOCAINE HCL VISCOUS,OXYCODONE ACETAMINOPHE,PENICILLIN V M 65 11,11,6,11,13,13,9,11, METOPROLOL SUCCINATE

27 Health Risk Screening Patern Recognition Glucose IRI BMI Frequency Health Risk Screening Patterns and Insurance Claims Example Use Cases Modifiable Health Risk Intervention Strategies Changes in Benefit Plan Design Predictive modeling on Health Expenditure Appropriate Allocation on Benefit Plans

28 While waiting for answers. Try to figure out how we could: Improve quality, safety, efficiency, and reduce health disparities Engage patients and families in their health care Improve care coordination Improve population and public health All the while maintaining privacy and security Explore where and how in the EHR or LIS (or both) we can deliver our values Quantify and qualify the value of these value-add services we provide to our clients (e.g., patients, clinicians, hospitals, health systems, payors) Why should we do these? Proactively prepare us for the emerging market forces Help steer the market demand by using HIT tools to position us toward the center of the healthcare delivery model It is our data We do not perform laboratory tests, We practice laboratory medicine.